Provider Demographics
NPI:1639476435
Name:DIEFENDERFER, JENNIFER L (PTA)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:L
Last Name:DIEFENDERFER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 ARMSTRONG ST
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21617-2125
Mailing Address - Country:US
Mailing Address - Phone:410-758-2323
Mailing Address - Fax:410-758-4493
Practice Address - Street 1:205 ARMSTRONG ST
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:MD
Practice Address - Zip Code:21617-2125
Practice Address - Country:US
Practice Address - Phone:410-758-2323
Practice Address - Fax:410-758-4493
Is Sole Proprietor?:No
Enumeration Date:2011-02-15
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDPTA-A3168225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant